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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001599
Report Date: 06/17/2025
Date Signed: 06/17/2025 04:11:58 PM

Document Has Been Signed on 06/17/2025 04:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ZACK, JERBANU PERVEZFACILITY NUMBER:
414001599
ADMINISTRATOR/
DIRECTOR:		ZACK, JERBANUPERVEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 627-8418
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
06/17/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Jerbanu ZackTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On 06/17/2025 at 1:35PM., Licensing Program Analyst (LPA), Luis Gomez met with Licensee, Jerbanu Zack. The purpose of today’s visit was explained and was for an unannounced, annual random inspection. Present was the licensee and assistant/ daughter caring for 7 children. All children presents are preschool-age. Adults in the home have criminal record clearances on file. The licensee’s home is a two- level house. Days and hours of operations are: Monday- Friday, 8:30AM- 5:30PM. The areas of the home designated for childcare are: Lower Level: Living Room (Playroom); Bathroom #1; and Backyard. The areas of the home designated as off-limits: Lower Level: Kitchen, The Entire Upper Level. LPA inspected facility indoors and outdoors for health and safety hazards.

At 1:40PM., the following was observed: Facility was clean, neat, with age-appropriate materials available for the children. The floors and ground surfaces were clear of any obstructions or hazards. Cubbies are available for storage of belongings. LPA observed table, chairs, scaled to the appropriate size. Accessible furniture, manipulative, and supplies inspected were in good repair, free of sharp corners.

For napping services, several mats are stored in facility. Per licensee, the napping supplies are washed weekly by families. Bathroom #1 was observed clean, with faucet and toilet in operating condition. The detergents, cleaning compounds, and item which can pose a danger, have been stored in the off-limit areas. Home was a comfortable temperature, ventilation, and sufficient lighting. Home has telephone service; carbon monoxide detector, smoke detectors; and fire extinguisher (2A:10BC). (REFER TO 809C, FOR CONT.)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ZACK, JERBANU PERVEZ
FACILITY NUMBER: 414001599
VISIT DATE: 06/17/2025
NARRATIVE
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(PAGE 2)
At 1:55PM., LPA inspected the backyard area. The area is completely enclosed with playthings in good repair. Home does not have any pools; fishpond; jacuzzi; or other bodies of water.

At 2:10PM., LPA reviewed facility records including the children and staff files. The staff/occupant file was reviewed and included the Proof of Immunization; and Notice of Employee Rights (LIC9052).

The children’s files were reviewed and included the: Identification and Emergency Information (LIC700); Notification of Parents Rights (LIC995); Immunization Records; and Health History.

Per licensee, CPR/ 1st aid training was completed on 1/24/2025. LPA reminded licensee cardiopulmonary resuscitation certificate is stored children's files.

LPA reminded licensee to renew mandated reporter training course (AB1207).

Facility is conducting emergency disaster drills every six months, with last drill completed on 2/11/2025, properly logged.

The required forms are posted in entry and include the: License; Notification of Parent’s Rights (PUB379); and Written Emergency Disaster Plan (LIC610).

Per licensee, isolation of an ill child is in the living room. (REFER TO 809C, FOR CONT.)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ZACK, JERBANU PERVEZ
FACILITY NUMBER: 414001599
VISIT DATE: 06/17/2025
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(PAGE 3)
Licensee was reminded that all adults 18 years and over living in the home, person who provides care and supervision to children, and staff who have contact with children, including employee and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain criminal clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

LPA discussed safe sleep regulations with licensee and the Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Facility was informed of the www.mychildcareplan.org site is a consumer education website that helps families obtain child care by connecting to child care providers and resources and referral agencies (R&R) throughout California.

Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 20-02-CCP. When an IMS is provided, a plan for IMS must be submitted to the department. the following information regarding ADA was provided: US Department of Justice (USDOJ) toll- free ADA information line at (800) 514-0301 (voice)/ (800) 514- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tool, please send them to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesource/community-care-licensing/inspection-process.(REFER TO 809C., FOR CONT.)

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ZACK, JERBANU PERVEZ
FACILITY NUMBER: 414001599
VISIT DATE: 06/17/2025
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(PAGE 4)
Based on today's inspection, no deficiencies were cited in areas evaluated according to California Title 22, Div. 12 Chap. 3, Health and Safety Code of Regulations. An exit interview and facility evaluation report was discussed with Licensees, Jerbanu Zack.

Licensee’s signature of this form acknowledges the receipt of these documents.

During exit interview, licensee confirmed no registered sex offenders are living in the facility, and LPA completed RSO profile. Notice of site visit was given and must remain posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Marie Rodriguez
NAME OF LICENSING PROGRAM ANALYST: Luis Gomez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5